‘We are not going to enforce our way out of this.’ Experts strategize new ways to fight opioid addiction

CLEVELAND — On Thursday night, two doctors and a drug law expert met in Cleveland. Their task? Come up with novel ways to fight an epidemic that kills 150 Americans every day.

America’s opioid crisis has become day after day of overdose stories, stunning photos, or new chemistries that are potent enough to kill even elephants. Cleveland Clinic’s CEO, Dr. Toby Cosgrove, former US Surgeon General Vivek Murthy, and Drug Enforcement Administration administrator Chuck Rosenberg sat down at a public forum Thursday night to strategize.

Here’s a snapshot of what they said.

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‘We have a war going on in our country on an annual basis.’

Cosgrove started the discussion with a graphic showing that 52,000 people died of drug overdoses in 2015, a more than twofold increase since 2002. A Vietnam veteran, he also pointed out that the death toll is nearly equal to the total number of Americans who died during the Vietnam War, which claimed 58,000 lives. He suggested that a more visual, in-your-face representation of the problem might stir action.

“I don’t think people recognize the magnitude of the problem,” Cosgrove said. “They don’t realize the seriousness of the drugs — the fentanyl and carfentanil. … The war in Vietnam was stopped by raising the consciousness of the American people. They saw the body bags coming into Andrews Air Force Base every night on the evening news. You don’t see that with this problem.”

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16 years of overdose deaths in the US

Explore the interactive visualization below to learn more about overdose deaths caused by narcotics and hallucinogens from 1999 to 2015. The vertical axis shows the number of people who died from a drug-related overdose in a year. The colored bands represent different types of drugs. "Other opioids" include morphine, oxycodone, and hydrocodone. The "other synthetic narcotics" category includes fentanyl, propoxyphene, and meperidine. Click on the colored bands to see the data broken down by drug type. Click on the arrows above the chart or the age groups at the bottom to see the data broken down by age.

‘It’s killing people sometimes on the first encounter.’

Rosenberg said two powerful opioids, fentanyl and carfentanil, are being laced into a variety of drugs, often without the knowledge of the user. It is not just getting mixed into heroin, he said, but cocaine and counterfeit prescription pills as well.

They are simpler to make, Rosenberg said, and even easier to sell. “The profit margin is immeasurably higher with fentanyl and carfentanil,” he said. “We are seeing it in many iterations all over the country.”

Fentanyl is 50 times stronger than heroin and carfentanil is 100 times stronger than fentanyl — merely handling them can cause an overdose. To protect its agents, the DEA has trained 1,100 of them to administer naloxone in case of an accident. Rosenberg referenced an incident in East Liverpool, Ohio, in which a local police officer overdosed after brushing some powder from his shirt after a drug stop. “It took four injections of naloxone to help save his life,” Rosenberg said. “This stuff can kill you to the touch.”

‘Health insurance coverage is essential for people to get treatment.’

Murthy did not mention the Republican-led American Health Care Act by name. But he noted that any reduction in coverage would be a major setback in the effort to fight the opioid crisis. The Congressional Budget Office estimated this week that the House’s Obamacare replacement would leave 23 million people uninsured over the next decade.

“If you are serious about addressing the opioid crisis in America, you have to be serious about expanding coverage because those two go hand in hand,” he said. Murthy urged members of the audience to contact members of Congress to urge them to push for greater coverage and other measures to expand access to naloxone and long-term treatment for drug users.

“These measures might be hard and politically controversial,” he said. “But this is a time when we need moral leadership in our country more than ever before.”

‘We’re not going to enforce our way out of this.’

Rosenberg emphasized that opioid addiction is a disease that must be treated with medicine, not incarceration. He said the DEA is getting increased cooperation from China to help stem the flow of synthetic opioids, and that his agency is targeting drug gangs and cartels that are distributing drugs. But he also emphasized that the public policy response must also focus on the demand side, to uproot addiction through education and treatment.

“This is a public health crisis and we have to change the culture,” he said. “If we don’t change the culture, then we don’t break the cycle. If we don’t break the cycle, this poison will continue to flow into the United States and kill our folks.”

He added that policy decisions should be guided by science, not opinion or ideology.

‘We need to find safer ways of addressing pain.’

Murthy said that clinicians must change the way they respond to pain,and be trained in other ways of treating it — like cognitive or physical therapy. “Part of the issue is that we would assess pain and then set a goal of having zero pain,” he said. “And opioids became our most effective tool to eliminate pain entirely. … But there are circumstances where eliminating pain entirely may not be our most important objective.”

Murthy added there is still a widely held misconception in the United States that addiction stems from a character flaw or results purely from poor choices. He said a culture shift is in order: “This is a disease of the brain and that has been well demonstrated by science. Once we recognize that, we can treat it the way we treat diabetes or heart disease, as a medical problem the deserves the same care, the same compassion, and the same urgent attention.”

So let’s just let the people in chronic pain suffer? This is infuriating as there are some diseases and conditions that are just as or MORE painful than many cancers. I have chronic pancreatitis from gallstones and am now basically bed ridden due to pain that is under treated. I did not ask to get this disease but I can tell you it is horrifically painful, I had natural childbirth and that was a walk in the park in comparrison! For these so called experts to just ignore the pain is beyond inhumane! The CDC broke many laws in the writing of the “guidelines” that have now became the law of the land, they violated constitutional rights and the guidelines should be rescinded immediately.We have a heroien and meth problem not a prescription problem, this so called epidemic has been blown out of porportion when you look at the fact that it does not even make the top 15 causes of death in this country and the numbers 52,000 out of 374 million does not make an epidemic. People are being harmed by this biased, unscientific agenda. Many have taken their lives because they could no longer take the pain. This is legal genocide! I think the money train is headed to Dr Kolodny! SMH!

Limiting opioids has already been proven to be ineffective or we should have seen a drop in deaths starting in 2013-2014, yet we are in 2017 and prescriptions continue to fall drastically and opioid deaths continue to rise dramatically.

I’m a chronic sufferer from stenosis, which I jokingly call “composer’s disease,” as we spend most of our working hours sitting at a piano.

From relief by Oxycodone of symptomatic pain, I have self-programmed a reduction from 150mg po to 45. This is not a cure-all. I occasionally postpone taking my last 15mg pill to the point where I can barely walk, but I’ve reached an equilibrium that allows me to function, do yoga, and participate in water aerobics.

My concern is that any One Size Fits All will lump me together with all the other pharmaceutical patients. For example, arbitrarily cutting my dose (which I’ve already self-reduced to 66%) to half. This would reduce me to pretty much no physical activity that requires standing or walking.

Yes, of course, I’ve tried alternative therapies…chiropractic, massage, acupuncture (which does NOTHING). I do not see a positive result from what I’ve read so far.

If the issue was reducing the number of deaths of people using street drugs &/or diverted Rx drugs, we would do what Portugal did in 2001, and lift the prohibition. Since this proven approach is not even being considered, the obvious conclusion is that the goal is not to reduce the numbers of deaths, but cynical use of these deaths to frighten the public about a supposed opioid/opiate epidemic.

We can’t know if there even *is* an epidemic of illegal use of opioids, opiates, heroin, &/or fentanyl because of two powerful incentives created by the drug war:
1. People who use such drugs illegally but also manage to work and function without getting into trouble are well aware of the draconian punishments from both the government (incarceration, criminal record, restrictions on future career, loss of educational grants & loans, civil forfeiture of everything the person owns) and socially (“tough love” which encourages throwing people out of home, family & social circles in service of forcing compliance).
2. People who are caught, whether for drug possession/sale or *a crime unrelated to drugs*, have strong incentives to claim to be hopelessly addicted, possibly being sent to rehab instead of jail, perhaps having the record expunged, maybe get a second chance from employer, family and/or the court. These incentives help support the narrative that drugs turn people into criminals.

As a result of the above facts that make a census of non-prescription users of drugs impossible, there is no way to know how many people are actually using medications and street drugs in ways the drug warriors disapprove of. The claim of an epidemic in progress is impossible to justify with such a gaping lack of data.

Another problem is the collection of data on the deaths that are being categorized as “opiate deaths’ or “overdose deaths”. 2/3 of US states do not have medical examiners, but instead elected coroners, most of whom are not required to have medical or science credentials. 1/2 of coroners’ offices have no in-house toxicology lab. But even so, just finding some amount of opioid, opiate or metabolite isn’t enough to prove this caused the death. Unlike cyanide, opiates don’t have a standard deadly dose because tolerance makes it possible to not only survive, but function, after a dose that might kill someone who had never ingested an opiate before. A study in the year 2000, attempting to find out the deadly dose for people who did have tolerance, compared methadone users whose deaths were classified as overdose with deaths that couldn’t be overdose, such as being hit by a vehicle. The “overdose” deceased had levels no higher than the second group, suggesting that even many of the deaths currently labeled as “overdose” may in fact be deaths that happened while these people had drugs in their bodies, but not necessarily *from* the drugs. With most ME & coroners’ offices having a budget of less than $3 per deceased, it would not be surprising if clues to opiate use end investigation.

As data is currently collected, deaths of people who had an Rx at the time of death, people who were using diverted Rx or counterfeit Rx or street fentanyl, are lumped together, which actually obscures any info about whether the amount of opioids prescribed – the *vast majority of which are used correctly and not diverted to illegal use* – are contributing at all to an increase in deaths of of people with legal prescriptions.

On top of the above problems with data collection, in Dec. 2016, the CDC used 59 deaths in MN 2006-2015, of people who had pneumonia and an opiate Rx at the time of death to support a recommendation that such deaths should be in the “opiate death” category, not pneumonia, as they had been recorded. If this is an *epidemic* why is the CDC scraping around for tiny numbers from years ago to boost the total? This demonstrates that we are discussing *not* deaths that have been scientifically-demonstrated to have been caused by this class of chemicals, but instead a *bureaucratic classification*, which is being presented to the public *as if it were* a scientifically-demonstrated fact.

The “opiate deaths” and/or “overdose deaths” numbers are always reported as either naked statistics – “deaths up x%” (which can sound huge, but if you add 5 to 5, you have a 100% increase, but still a tiny number) or compared to one other naked statistic. For the past year or so, the second naked statistic has been automobile crash deaths, annual average 32-33,000, and in this article, Vietnam war deaths, 58,000. Why not compare to tobacco’s annual average of 480,000, many years after quitting or second hand exposure? Tobacco also causes characteristic damage to every organ of the body, from the wrinkles around the mouth, to hardened blood vessels, reproductive difficulties, even in users who don’t died from tobacco-related cancers.

I searched for a similar pattern of damage from long term opiate/opioid use, but it seems the few side effects, slowing of the bowel and lung function, for example, go away once the medication is ceased.

Another interesting thing about the mention of the Vietnam War – about 40% of US soldiers stationed in Vietnam experimented with heroin, and 20% were hooked by the time they left Vietnam. Of the latter, 95% quit without difficulty on returning home. This didn’t happen because these soldiers came home to incarceration, career-killing criminal records, confiscation of everything they own, or “tough love” protocols of family & friends turning their backs on these veterans. And going to meetings to train themselves to believe they were “powerless” over heroin wasn’t part of the equation.

Our government is currently trapped in a long-standing and pernicious groupthink surrounding the idea that certain drugs make people unfit as citizens and that the government can and should eliminate such drugs. This has led to more than a century of prohibition, 47 years of the “war on drugs”, dozens of federal agencies doing all or most of their work on either the drug war or supporting the addiction industry (many other federal and state agencies contributing money & workforce to the project), and the very government that has been doing all this and spending $51 billion/yr categorizing current use of black market drugs as epidemic.

The only reason I can see for discouraging the use of opiates/opioids for severe pain, especially for severe chronic pain, is that such patients are, like the Vietnam war vets half a century ago, living proof that such drugs do not turn people into criminals, and that these medications, with a very few, clear instructions, are the safest way to treat pain.

Thank you for such a thorough and well thought out analysis. Totally agree on the utility (and futility, here) of the model set by Portugal. Not total agreement on alternatives to opiates for severe chronic pain, I think there is a lot of work to be done, but it isn’t getting done. Not done, because a) it’s not profitable and b) we never support prevention anyway (“Just say no” doesn’t count!) because it’s not profitable. And, unfortunately, doctors (particularly in ED settings) and dentists have not gotten the message about limiting prescriptions.

Thanks for your reply. I have done a great deal of research on alternatives to opiates, and as far as I can tell, they are among the safest medications in the pharmacopeia.

Actually, I would be willing to bet the house that large pharmaceutical companies are looking very hard to the safe opiate alternative, because there is political will to shut the supply of opiates even to people with chronic severe pain who have never abused their prescriptions, in the service of messaging about addiction, and if such a treatment could be found, it would be an enormous moneymaker.